Chinese Medical Journal 2009;122(24):2945-2950 2945

Original article
A prospective study comparing endoscopic subcutaneous
mastectomy plus immediate reconstruction with implants
and breast conserving surgery for breast cancer
FAN Lin-jun, JIANG Jun, YANG Xin-hua, ZHANG Yi, LI Xing-gang, CHEN Xian-chun and ZHONG Ling

Keywords: breast neoplasm; endoscope; subcutaneous mastectomy; segmental mastectomy; breast implant

Background Breast conserving surgery (BCS) has been the standard surgical procedure for the treatment of early
breast cancer. Endoscopic subcutaneous mastectomy (ESM) plus immediate reconstruction with implants is an emerging
procedure. The objective of this prospective study was to evaluate the clinical outcomes of these two surgical procedures
in our clinical setting.
Methods From March 2004 to October 2007, 43 patients with breast cancer underwent ESM plus axillary lymph node
dissection and immediate reconstruction with implants, while 54 patients underwent BCS. The clinical and pathological
characteristics, surgical safety, and therapeutic effects were compared between the two groups.
Results There were no significant differences in the age, clinical stage, histopathologic type of tumor, operative blood
loss, postoperative drainage time, and postoperative complications between the two groups (P >0.05). The postoperative
complications were partial necrosis of the nipple and superficial skin flap in the ESM patients, and hydrops in the axilla
and residual cavity in the BCS patients. There was no significant difference in the rate of satisfactory postoperative
cosmetic outcomes between the ESM (88.4%, 38/43) and BCS (92.6%, 50/54) patients (P >0.05). During follow-up of 6
months to 4 years, all patients treated with ESM were disease-free, but 3 patients who underwent BCS had metastasis or
recurrence — one of these patients died of multiple organ metastasis.
Conclusions After considering the wide indications for use, high surgical safety, and favorable cosmetic outcomes, we
conclude that ESM plus axillary lymph node dissection and immediate reconstruction with implants — the new surgery of
choice for breast cancer — warrants serious consideration as the prospective next standard surgical procedure.
Chin Med J 2009;122(24):2945-2950

B reast conserving surgery (BCS), the standard surgical

procedure for the treatment of early breast cancer, is
not markedly different from modified radical mastectomy
in long-term survival rates; the procedures vary, however,
in local recurrence rates even after administering diligent
postoperative radiotherapy.1-3 Furthermore, a wide local
excision will almost always result in a smaller-sized
breast.4,5 To explore the suitability of a new procedure,
we compared the clinical outcomes of endoscopic
subcutaneous mastectomy (ESM; plus axillary lymph
node dissection and immediate reconstruction with
implants) with BCS.
METHODS
Enrollment and grouping of patients
This prospective study enrolled 97 patients with breast
cancer between March 2004 and October 2007. All
patients were informed of and allowed to select
procedures preoperatively, then assigned to the ESM
group (n=43, treated with ESM plus axillary lymph nodes
dissection and immediate reconstruction with implants) or
the BCS group (n=54, treated with BCS) according to
their preference and disease condition.
The inclusion criteria for patients were: female; less than
55 years of age; invasive breast cancer confirmed
histopathologically by preoperative core needle biopsy or
excision biopsy; tumor not larger than 3 cm on primary
examination or after neoadjuvant chemotherapy; absence
of deviation or retraction of the nipple; absence of
obviously enlarged or fused axillary lymph nodes;
absence of distant metastasis found by auxiliary
examination; and consent for neoadjuvant chemotherapy
with the TE regimen (taxol 175 mg/m2, epirubicin 80
mg/m2, IV day 1; cycled every 21 days for 1–4 cycles).
In addition, patients in the ESM group were required to
have each breast less than 350 ml in volume without
obvious mastoptosis; absence of dimple sign or Peau d′
orange on the surface of the breast; a distance of more
than 0.5 cm between the tumor surface and skin determined
DOI: 10.3760/cma.j.issn.0366-6999.2009.24.005
Center of Breast Disease, Southwest Hospital, Third Military
Medical University, Chongqing 400038, China (Fan LJ, Jiang J,
Yang XH, Zhang Y, Li XG, Chen XC and Zhong L)
Correspondence to: Prof. JIANG Jun, Center of Breast Disease,
Southwest Hospital, Third Military Medical University, Chongqing
400038, China (Tel: 86-23-68754160. Fax: 86-23-65310689.
Email: flj212@medmail.com.cn)
This study was supported by a grant from Clinical Study
Foundation of Southwest Hospital, Third Military Medical
University (No. SWH2006B012).
2946 Chin Med J 2009;122(24):2945-2950

Figure 1. Setting up an operating space for endoscopic subcutaneous mastectomy after lipolysis and liposuction.
Figure 2. Transecting Cooper ligaments between skin and gland with an electric hook under endoscopic monitoring.
Figure 3. Excising the gland superior to the tumor (marked by methylene blue) for intraoperative frozen section analysis.
Figure 4. Implanting a prosthesis into the retropectoral space through the superior incision after axillary lymph node dissection.
Figure 5. Fair cosmetic outcome in a patient from the endoscopic subcutaneous mastectomy group 3 months after surgery.
Figure 6. Poor cosmetic outcome and deformity of the treated breast in a patient from the breast conserving surgery group because of
small breast size and large tumor size (3 cm in diameter).

during preoperative ultrasound; intraoperative frozen
section analysis (FSA) of the glands inferior to the nipple
and superior to the tumor showing no infiltration of
cancer; and the possibility of the prosthesis being
accepted psychologically. At the same time, patients in
the BCS group were required to have had: no multicentric
lesions present during preoperative ultrasound and with
molybdenum target X-ray; a distance of more than 1 cm
between the tumor margin and the areolar margin, and an
intraoperative FSA displaying no infiltration of cancer
into the incisal margin; no previous radiotherapy on the
diseased breast and ipsilateral chest wall; no collagenosis
such as systemic lupus erythematosus and scleroderma, or
any other contraindications for radiotherapy; and consent
for BCS and postoperative radiotherapy.
Operation procedures
ESM group
ESM under general anesthesia with tracheal intubation,
the patient was placed in a supine position with the
diseased side raised by 15°–30° and the ipsilateral arm
abducted to 90° and fixed to the headframe. Incisions of
0.5 cm in length were made at the axillary transverse
striation beyond the superolateral margin of the breast
(superior incision), the midaxillary line at the nipple level
(lateral incision), and the anterior axillary line at the
inferolateral margin of the breast (inferior incision).
Lipolysis solution (250 ml of sterile purified water, 250 ml
of physiological saline, 20 ml of 2% lidocaine, and 1 ml of
0.1% adrenaline mixed as a 521-ml solution) was injected
into the subcutaneous and retromammary spaces through
the three incisions. The amount of solution injected
(about 500–800 ml into each side) was adjusted
depending on the size of the breast. Ten minutes after
injection of the lipolysis solution, sufficient liposuction
was performed in the subcutaneous and retromammary
spaces of the breast via the lateral and inferior incisions
using a metal aspiration tube with side apertures (a
suction tip used for uterine curettage) to remove the
adipose tissue around the breast gland, especially the fat
inferior to the nipple and superior to the tumor. Then a
5-mm trocar was inserted into each of the incisions and
CO2 was insufflated to establish an operating space
(Figure 1). The inflation pressure was maintained at 8 mmHg.
After sufficient liposuction, there remained only the
Cooper ligaments between the gland and skin, the major
ducts between the gland and nipple, and the marginal
glands connecting the surrounding fascia around the
retromammary space, which were then transected using
an electric hook under endoscopic monitoring (Figure 2).
The superior incision was then extended to 5 cm along
the axillary transverse striation to remove the glands.
Furthermore, with the help of the mark for tumor area
with methylene blue, the tissues inferior to the nipple and
superior to the tumor were taken for intraoperative FSA
(Figure 3). After the excision, regional flushing, and
thorough hemostasis, the endoscope and trocars were
taken out.
Axillary lymph node dissection
Through the extended superior incision, axillary flaps
were dissociated; the pectoralis minor was disclosed
along the outer edge of the pectoralis major and the
coracoclavicular fascia was opened at the outer edge of
Chinese Medical Journal 2009;122(24):2945-2950
the pectoralis minor to expose the axillary vein. The
axillary lymph nodes above level II were then dissected.
Prosthesis implantation
From the lateral border to the medial and inferior margin
of the pectoralis major, the retropectoral space was fully
separated through the superior incision, and the partial
attachment of the pectoralis major was cut off when
necessary. In light of the volume of the excised gland and
contralateral breast size, a suitable prosthesis of 180–260 ml
that exactly matched the volume of the excised gland and
the contralateral breast was selected and placed into the
retropectoral space (Figure 4). A latex drainage tube was
placed in the residual cavity near the submammary fold,
educed through the inferior incision, and fixed firmly;
another tube was placed in the axilla, educed through the
lateral incision, and fixed firmly. After the operation, a
mild compression dressing was applied for at least 2
weeks to avoid upward displacement of the prosthesis.
BCS group lumpectomy
Under general anesthesia with tracheal intubation, a
transverse fusiform incision in the upper inner and upper
outer quadrants, or a radiate fusiform incision in the
lower quadrants was made, which was at least 1 cm away
from the border of the tumor. Skin flaps with thin
subcutaneous fat were dissociated to more than 2 cm
away from the tumor margin, and the tumor with its
surrounding normal tissue of about 1-cm thick was
resected radially; tumor incisional margins were marked
for FSA. When FSA showed cancer infiltration, the
incisional margins were extended by 1 cm. When the
margin was found positive after a second examination, a
modified radical mastectomy was performed.
Axillary lymph node dissection
A 6-cm incision was made along the axillary transverse
striation between the outer edge of the pectoralis major
and the anterior edge of the latissimus dorsi, through
which the axillary lymph node dissection was performed
as in the ESM group. After the surgical procedure, a
drainage tube was placed in the axilla, which was
subjected to a mild, negative-pressure suction.
Postoperative management
As a preventive measure, antibiotics were administered
for 3 to 5 days after the operation. The drainage tubes
were removed when they drained less than 10 ml of fluid
per day. Postoperative chemotherapy was given in 4 to 6
cycles to all patients (as in neoadjuvant chemotherapy).
Radiotherapy of the affected breast was performed
routinely in the BCS group and not routinely in the ESM
group; radiotherapy of the internal mammary, axillary,
and infraclavicular regions was performed in patients
when more than four axillary lymph nodes were involved.
After radiotherapy, patients with positive results from
analysis of the tumor for estrogen receptors or
progestogen receptors were managed with endocrine
therapy for five years.
2947
Follow-up
After treatment, all patients were followed up in the
out-patient department every 3 to 6 months. Patients who
did not attend the out-patient department for follow-up
were contacted using questionnaires through the mail or
over the telephone.
Evaluation criteria for postoperative cosmetic effect
The cosmetic outcome6 was evaluated 3 months after the
surgical procedure. The items scored were: the
appearance of the surgical scar; breast size; breast shape;
nipple position; and areolar shape. While scoring these
items, the treated breast was compared with the
contralateral breast using a 4-point scale: excellent (0),
when there was no difference between the breasts; good
(1), when there was only a slight difference; fair (2),
when a marked difference was present, which could be
masked by dress; and poor (3), when the difference was
disturbing.
Statistical analysis
Statistical analysis were performed using SPSS 13.0
(SPSS Inc Chicago, USA). Continuous variables and
constituent ratio were expressed as mean ± standard
deviation (mean ± SD). Comparisons between the two
groups were made using a two-tailed Student′s t test for
measurement data and chi-square test for enumeration
data. Difference was considered statistically significant
when the P value was less than 0.05.
RESULTS
Clinical and pathological characteristics of the two
groups
There were no differences in patient age, tumor size,
tumor staging (according to the AJCC Cancer Staging
Atlas, the 6th edition7), pathological type of tumor, status
of hormone receptors and Her-2, and preoperative
chemotherapy cycles between the two groups (P >0.05).
However, the average distance between the tumor and
areola was significantly shorter in the ESM group
(2.2±1.1) than in the BCS group (3.4±1.3) (P <0.01);
there were eight patients with sub-areolar lesions in the
ESM group (Table).
Operation results
Intraoperative FSA showed no infiltration of cancer into
the subcutaneous tissue superior to the tumor in the ESM
group and no residual cancer in the incisional margin
tissue in the BCS group. There were no significant
differences in volumes of blood lost and postoperative-
drainage-duration between the two groups (P >0.05);
however, the duration of surgery was markedly longer in
the ESM group than in the BCS group (P <0.01). In the
ESM group, the total time of lipolysis and liposuction
was about 30 minutes (Table).
Postoperative complications
The major complications in the ESM group (with a total
2948 Chin Med J 2009;122(24):2945-2950

Table. Analysis of clinical and pathological characteristics of breast cancer in the two groups
Parameter ESM group BCS group t or χ2 value P value
No. of patients 43 54
Age (years) 39.7±8.2 42.4±7.9 1.624 0.108
Tumor size (cm) 2.7±0.9 2.6±0.9 0.429 0.669
Distance from the areola (cm) 2.2±1.1 3.4±1.3 5.001 <0.01
Tumor staging 0.687 0.709
I 15 22
II 22 27
IIIA 6 5
Pathological types 0.492 0.569
Infiltrating ductal cancer 38 45
Other infiltrating cancer 5 9
Hormone receptor-positive rate 23/43 29/54 0.000 1.000
Her-2 positive rate 16/43 24/54 0.517 0.536
Preoperative chemotherapy cycles 2.1±1.1 1.9±1.1 1.181 0.241
Operation duration (minutes) 168±32 139±37 4.094 <0.01
Intraoperative blood loss (ml) 115±44 102±48 1.409 0.162
Postoperative drainage volume (ml) 150±63 160±69 0.726 0.470
Postoperative drainage duration (days) 6.7±2.1 6.3±2.1 1.070 0.284
Postoperative complications 5/43 6/54 0.006 1.000
Satisfactory postoperative cosmetic outcome 38/43 50/54 0.507 0.504
Follow-up time (months) 16.9±11.2 20.1±11.9 1.332 0.186
Recurrence and metastasis 0/43 3/51 2.613 0.247
Total survival 43/43 50/51 0.852 1.000

incidence of 11.6% (5/43)) were partial necrosis of the
nipple in 2 patients, and superficial island necrosis and
blistering of the breast skin in 3 patients. These
complications healed with little change in breast
appearance after incrustation and decrustation. No
complete nipple necrosis or subcutaneous hydrops were
observed in any patient. In the BCS group, the
complications were hydrops in the axilla and residual
cavity with a total incidence of 11.1% (6 of 54), which
were treated successfully by puncturing and re-draining
within 1 month. There was no significant difference in the
total incidence of complications between the two groups
(P >0.05).
Follow-up results
All of the 43 patients in the ESM group and 51 of the
patients (94.4%, 51/54) in the BCS group were followed
up for 6 months to 4 years. Patients in the ESM group all
had a disease-free-survival, while 3 patients in BCS
group had distant metastasis or local recurrence. Of these
3 patients, one had multiple bone metastases and liver
metastasis 37 months after the operation and died of
multiple organ failure 41 months after surgery as a
consequence of abandoning treatment; one developed
massive ascites and intra-abdominal multiple metastases
15 months after surgery and was stable after
chemotherapy and symptomatic treatment; the third
patient had local recurrence 28 months after the operation,
and survived after modified radical mastectomy,
postoperative chemotherapy, and radiotherapy. However,
there were no statistically significant differences in total
survival, local recurrence, and distant metastasis between
the two groups (P >0.05).
Postoperative cosmetic evaluation showed (Figures 5 and
6) that in the ESM group, the outcome achieved was
excellent in 9 patients (20.9%), good in 16 patients
(37.2%), fair in 13 (30.2%) and poor in 5 (11.6%), with a
total satisfactory rate (excellent + good + fair) of 88.4%
(38/43). Among the 5 patients with poor cosmetic
outcome, 2 patients had serious asymmetry because of the
upper reconstructed breast and the ptotic untreated one
and 3 because of a smaller reconstructed breast and a
bigger untreated one. The reconstructed breast was
slightly higher than the contralateral breast during the
initial stage after surgery in the ESM group, which
resulted in discontentment with the cosmetic outcome.
However, three months later, the cosmetic effect
improved because the reconstructed breast shifted
downwards and molded and had subcutaneous fat
deposition. In the BCS group, the total satisfactory rate
was 92.6% (50/54); the 4 patients with a poor cosmetic
result had marked asymmetry because of the excess
removal of glands and skin. There was no significant
difference in the rate of satisfactory cosmetic outcome
between the two groups (χ2=0.507, P=0.504).
DISCUSSION
ESM can reduce the use of breast radiotherapy
treatment for breast cancer
The evolution of breast cancer treatment from radical
mastectomy to modified radical mastectomy to BCS
illustrates the continual need for improvement of surgical
concepts and techniques in breast surgery — all in pursuit
of “cure of breast cancer concomitant with maximal
conservation of tissue” amongst both doctors and patients.
BCS includes lumpectomy plus axillary lymph node
dissection with postoperative breast radiotherapy for all
cancer stages to avoid recurrence, the reported local
recurrence rate in the literature was 26.4% without breast
radiotherapy.8 In our study, patients in the BCS group
underwent outpatient radiotherapy once a day for more
than one month. This prolonged the total therapy time and
Chinese Medical Journal 2009;122(24):2945-2950
resulted in complications such as skin damage, breast
edema, radiation pneumonitis,9 and, in addition, increased
pain and financial burden for patients.10 In contrast,
patients treated with ESM could avoid postoperative
breast radiotherapy because of the total removal of the
glands and, thus, did not suffer from radiation-based
complications, postoperative local recurrence, and breast
stump carcinoma. In this study, there were no significant
differences between the two groups in prognostic factors
such as tumor staging, hormone receptor status, and
Her-2 status. Three patients in the BCS group developed
recurrence and metastasis postoperatively in spite of the
regular radiotherapy, while all patients in the ESM group
survived disease-free; however, the differences between
the two groups were not statistically significant, probably
because of the small number of patients studied.
Wider indications for ESM plus axillary lymph node
dissection and immediate breast reconstruction
compared with BCS
Patients with a tumor of more than 3 cm in diameter, less
than 2 cm away from the areola, or with multicentric
lesions should be excluded from BCS.4 However, ESM
has no severe limitations imposed by tumor size and
position as long as the skin and main duct are not affected
by the cancer. In addition, ESM is also suitable for the
multicentric lesion, which is one of the key factors
causing postoperative recurrence after BCS.11,12
Central breast cancer is considered a contraindication for
BCS and modified mastectomy with conservation of the
nipple/areola complex.13 The literature suggests that the
chances of malignant nipple/areola involvement may
have been overestimated.14 In the ESM group that
included 8 patients with central breast cancer, the distance
between the tumor and areola was much shorter than that
in the BCS group; no cancer infiltration of the
subcutaneous tissue over the tumor was found using
intraoperative FSA, and no cancer recurrence or
metastasis were observed during the follow-up period.
Therefore, central breast cancer without the involvement
of the nipple/areola and skin (observed during
preoperative examination) can be managed with ESM.
The indications for selecting ESM plus axillary lymph
node dissection and immediate breast reconstruction are,
therefore, wider than BCS.
Feasibility and surgical safety of ESM plus axillary lymph
node dissection and immediate breast reconstruction
The use of endoscopic techniques for subcutaneous
excision of breast tumors is well established.15-17 ESM
was performed through small incisions made in hidden
sites after sufficient lipolysis and liposuction, axillary
lymph node dissection, and finally prosthesis
implantation through the axillary incision. In our study,
the duration of surgery in the ESM group was longer (an
average duration of 168 minutes) than that of the BCS
group, where an incision was made directly on the tumor
surface and excision was performed under direct vision.
2949
Lipolysis and liposuction are time-consuming, and the
longer duration of surgery might also be partly due to the
unskilled technique of the surgeon in the ESM group.
To avoid residual cancer after ESM, the case-inclusion
criteria have to be strictly enforced and FSA of the tissue
inferior to the nipple and superior to the tumor must be
meticulously performed intraoperatively. In the ESM
group in our study, no recurrence or metastasis occurred
during follow-up, indicating that proper endoscopic
techniques were employed and our case-selection criteria
were adequate.
The postoperative complications in our ESM group were
partial necrosis of nipple and superficial necrosis of the
breast skin, which were caused by insufficient blood
supply to the nipple. Nipple blood supply comprises two
parts: the vascular network from the surrounding skin and
subcutis; and the perforating vessels from the mammary
gland. After a subcutaneous mastectomy, the nipple
depends for its blood supply only on the vascular network
from the surrounding skin and subcutis.18 In the ESM
group, 2 patients suffered from partial nipple necrosis and
3 from superficial skin necrosis — all healed with little
change of appearance within a month. These
complications were avoided by refinement of the surgical
skills required for the procedure; therefore, no nipple
necrosis was found among the remaining 38 patients in
the ESM group. To avoid subcutaneous vascular network
injury, we suggest that the tip of the suction nozzle not
face the skin during liposuction. In addition, we also
suggest that a small amount of the gland be spared
beneath the nipple and areola to prevent ischemia and
aversion. The postoperative complication in the BCS
group was subcutaneous hydrops, which was caused by
impaired lymphatic drainage and lymph leakage.19
Subcutaneous hydrops did not occur with ESM because
the entire breast tissue, the source of lymph, was resected.
Postoperative cosmetic effect of ESM plus axillary
lymph node dissection and immediate breast
reconstruction for breast cancer
One of the aims of BCS and ESM is to retain the original
breast contour (for cosmetic reasons) after surgery.20-22
After a wide local excision in a large breast, the
postoperative contour is usually satisfactory; but this can
be a challenge with small-sized breasts because it is
difficult to maintain symmetry with the contralateral
breasts.4 Among the 54 patients in the BCS group of this
study, 4 patients with small breasts had poor cosmetic
results because of asymmetry. With ESM, subcutaneous
mastectomy can be performed though 3 incisions hidden
beyond the breast margins, which will conserve skin,
while the prosthesis can be inserted though the axillary
incision to reconstruct the original breast contour, all
resulting in acceptable postoperative cosmetic results.
This is ideal for medium- and small-sized breasts where
maintaining bisymmetry is a challenge. For large-sized or
drooping breasts, endoscopic surgery is difficult and
2950
time-consuming to perform. Moreover, the reconstructed
breast usually lacks natural ptosis and will be smaller
than the untreated breast because the prosthesis can only
be inserted into the retropectoral space, which has a
limited interstitial volume. Breast reconstruction is,
therefore, not suitable for patients with large or drooping
breasts, where better cosmetic results can be achieved by
autologous tissue flap transfer.23
In our study, even though the difference in rates of
satisfactory cosmetic outcomes between the ESM and
BCS groups was not statistically significant, the cosmetic
effect was worse in the ESM group (88.4%; BCS group,
92.6%). The possible reasons for this are prosthesis
deviation due to technical factors, uneven symmetry
because of ptotic or larger contralateral normal breast, and
unrealistic expectations of cosmetic outcome after surgery
in some patients who underwent ESM. To achieve optimal
aesthetic results, we recommend that BCS be used in
patients with large breasts and ESM plus axillary lymph
node dissection and breast reconstruction with implants be
used in patients with small, non-droopy breasts.
After considering the wide indications for use, high
surgical safety factor, and favorable cosmetic outcome,
we believe that ESM plus axillary lymph node dissection
and immediate reconstruction with implants — the new
choice in surgery for breast cancer — warrants serious
consideration as the prospective next standard surgical
procedure.
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(Received May 29, 2009)
Edited by HAO Xiu-yuan and PAN Cheng